NATIONAL MEDICAL SUPPORT NOTICE - PART A
NOTICE TO WITHHOLD FOR HEALTH CARE COVERAGE
This Notice is issued under section 466(a)(19) of the Social Security Act, section 609(a)(5)(C) of the Employee Retirement
Income Security Act of 1974 (ERISA), and for State and local government and church plans, sections 401(e) and (f) of the
Child Support Performance and Incentive Act of 1998. Receipt of this Notice from the Issuing Agency constitutes receipt
of a Medical Child Support Order under applicable law. The information on the Custodial Parent and Child(ren) contained
on this page is confidential and should not be shared or disclosed with the employee. NOTE: For purposes of this form,
the Custodial Parent may also be the employee when the State opts to enforce against the Custodial Parent.
Issuing Agency: ________________________________
Issuing Agency Address: ________________________
_____________________________________________
Notice Date: __________________________________
CSE Agency Case Identifier: ______________________
Telephone Number:______________________________
FAX Number:___________________________________
_________________________________________
Employer/Withholder’s Federal EIN Number
_________________________________________
Employer/Withholder’s Name
_________________________________________
_________________________________________
_________________________________________
Employer / Withholder’s Address
_________________________________________
Custodial Parent’s Name (Last, First, MI)
_________________________________________
_________________________________________
_________________________________________
Custodial Parent’s Mailing Address
_________________________________________
_________________________________________
_________________________________________
Child(ren)’s Mailing Address (if different from
Custodial Parent’s)
_________________________________________
Name and Telephone of a Representative of the
Child(ren)
Child(ren)’s Name(s
Gender DOB
SSN
____________________ _____ ________ _____
____________________ _____ ________ _____
____________________ _____ ________ _____
RE:
Court or Administrative Authority: __________________
Order Date: ___________________________________
Order Identifier: ________________________________
Document Tracking Identifier: _____________________
Employer web site: _____________________________
See NMSN Instructions: www.acf.hhs.gov/programs/cse/forms/
____________________________________________
Employee’s Name (Last, First, MI)
____________________________________________
Employee’s Social Security Number
____________________________________________
____________________________________________
____________________________________________
Employee’s Mailing Address
____________________________________________
Substituted Official/Agency Name
____________________________________________
____________________________________________
____________________________________________
Substituted Official/Agency Address
(Required if Custodial Parent’s mailing address is left blank)
____________________________________________
____________________________________________
____________________________________________
Mailing Address of a Representative of the Child(ren)
Child(ren)’s Name(s)
____________________
____________________
____________________
Gender DOB
_____ ________
_____ ________
_____ ________
SSN
________
________
________
The order requires the child(ren) to be enrolled in  all health coverages available; or only the following coverage(s):
 Medical; Dental; Vision; Prescription drug;  Mental health; Other specify):________________________
THE PAPERWORK REDUCTION ACT OF 1995 (P.L. 104-13) Public reporting burden for this collection of information is estimated to
average 10 minutes per response, including the time reviewing instructions, gathering and maintaining the data needed, and reviewing the
collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information
unless it displays a currently valid OMB control number. OMB control number: 0970-0222 Expiration Date: 03/31/2014.
Page 1 of 5
LIMITATIONS ON WITHHOLDING
The total amount withheld for both cash and medical support cannot exceed ____________% of the employee’s
aggregate disposable weekly earnings. The employer may not withhold more under this National Medical Support Notice
than the lesser of:
1. The amounts allowed by the Federal Consumer Credit Protection Act (15 U.S.C., section 1673(b));
2. The amounts allowed by the State of the employee’s principal place of employment; or
3. The amounts allowed for health insurance premiums by the child support order, as indicated
here:_________________________________.
The Federal limit applies to the aggregate disposable weekly earnings (ADWE). ADWE is the net income left after making
mandatory deductions such as State, Federal, local taxes; Social Security taxes; and Medicare taxes. As required under
section 2.b.2 of the Employer Responsibilities on page 4, complete item 5 of the Employer Response to notify the Issuing
Agency that enrollment cannot be completed because of prioritization or limitations on withholding.
PRIORITY OF WITHHOLDING
If withholding is required for employee contributions to one or more plans under this notice and for a support obligation
under a separate notice and available funds are insufficient for withholding for both cash and medical support
contributions, the employer must withhold amounts for purposes of cash support and medical support contributions in
accordance with the law, if any, of the State of the employee’s principal place of employment requiring prioritization
between cash and medical support, as described here: __________________________________________________.
As required under section 2.b.2 of the Employer Responsibilities on page 4, complete item 5 of the Employer Response to
notify the Issuing Agency that enrollment cannot be completed because of prioritization or limitations on withholdings.
Page 2 of 5
EMPLOYER RESPONSE
If 1, 2, 3, 4 or 5 below applies, check the appropriate box and return this Part A to the Issuing Agency within 20
business days after the date of the Notice, or sooner if reasonable. NO OTHER ACTION IS NECESSARY. If 1
through 5 does not apply, complete item 7 and forward Part B to the appropriate Plan Administrator(s) within 20
business days after the date of the Notice, or sooner if reasonable. This includes any organization or labor
union that provides group health care benefits to the employee. Check number 5 and return this Part A to the
Issuing Agency if the Plan Administrator informs you that the child(ren) would be enrolled in or qualify(ies) for
an option under the plan for which you have determined that the employee contribution exceeds the amount that
may be withheld from the employee’s income due to State or Federal withholding limitations and/or prioritization.
You are required to respond to the Issuing Agency by returning this Employer Response regardless of whether
you provide group health benefits or the employee named herein is no longer employed by your organization.
Information for the Plan Administrator and the Employer Representative at the bottom of this section is required.
 1. The employee named in this Notice has never been employed by this employer.
 2. We, the employer, do not offer our employees the option of purchasing dependent or family health care
coverage as a benefit of their employment.
 3. The employee is among a class of employees (for example, part-time or non-union) that are not eligible
for family health coverage under any group health plan maintained by the employer or to which the employer
contributes. Do not check this box if the employee is only temporarily ineligible for health care coverage.
 4. Health care coverage is not available because employee is no longer employed by the employer:
Date of termination: _______________________________
Last known telephone number: ______________________
Last known address: _______________________________
New employer (if known): __________________________
New employer telephone number: ____________________
New employer address: _____________________________
 5. State or Federal withholding limitations and/or prioritization prevent the withholding from the employee’s
income of the amount required to obtain coverage under the terms of the plan.
 6. The participant is subject to a waiting period that expires _________ (more than 90 days from the date of
receipt of this Notice), or has not completed a waiting period, which is determined by some measure other than
the passage of time, such as the completion of a certain number of hours worked (describe here:
________________). At the completion of the waiting period, the Plan Administrator will process the
enrollment.
 7. Employer forwarded Part B to Plan Administrator on _______________.
MM/DD/YY
CONTACT FOR QUESTIONS
Plan Administrator Name: _______________________________
Contact Person: ______________________________________
FAX Number: ____________________
Telephone Number: _______________
Employer Name: ______________________________________
Employer Representative Name/Title: ______________________
Telephone Number: ________________
Federal EIN: _____________________
(if not provided on Page 1 of this Notice)
Date: ___________________________
Employee Name: ______________________________________
Page 3 of 5
INSTRUCTIONS TO EMPLOYER
This document serves as legal notice that the employee identified on this National Medical Support Notice is
obligated by a court or administrative child support order to provide health care coverage for the child(ren)
identified on this Notice. This National Medical Support Notice replaces any Medical Support Notice that the
Issuing Agency has previously served on you with respect to the employee and the children listed on this Notice.
The document consists of Part A - Notice to Withhold for Health Care Coverage for the employer to withhold
any employee contributions required by the group health plan(s) in which the child(ren) is/are enrolled; and Part
B - Medical Support Notice to the Plan Administrator, which must be forwarded to the Administrator of each
group health plan identified by the employer to enroll the eligible child(ren), or completed by the employer, if the
employer serves as the health Plan Administrator.
An employer receiving this legal Notice is required to complete and return Part A. If group health coverage is
not available to the employee named herein, or the employee was never or is no longer employed, the employer
is still required to complete Part A – Employer Response and return it to the Issuing Agency with the
appropriate response checked. If you, the employer, provide the health care benefits to the employee, forward
Part B – Plan Administrator Response to the health Plan Administrator of your organization. If the
employee’s health care benefits are administered through another organization, including a labor union, forward
Part B of the Notice to the labor union or other organization acting as the Plan Administrator for completion. If
the employee has already enrolled the child(ren) in health care coverage, the employer must forward Part B to
the Plan Administrator for completion and submittal to the Issuing Agency.
Keep a copy of Part A as it may be used to notify the Issuing Agency if the employee separates from service for
any reason including retirement or termination.
EMPLOYER RESPONSIBILITIES
1.
If the individual named in this Notice is not your employee, or if the family health care coverage is not
available, please complete item 1, 2, 3, 4 or 5 of the Employer Response as appropriate, and return it to
the Issuing Agency. NO OTHER ACTION IS NECESSARY.
2.
If family health care coverage is available for which the child(ren) identified above may be eligible, you
are required to:
a.
Transfer, not later than 20 business days after the date of this Notice, a copy of Part B
Medical Support Notice to the Plan Administrator to the Administrator of each appropriate
group health plan for which the child(ren) may be eligible, complete item 7, and
b.
Upon notification from the Plan Administrator(s) that the child(ren) is/are enrolled, either
1) withhold from the employee’s income any employee contributions required under each group
health plan, in accordance with the applicable law of the employee’s principal place of
employment and transfer employee contributions to the appropriate plan(s), or
2) complete item 5 of the Employer Response to notify the Issuing Agency that enrollment
cannot be completed because of prioritization or limitations on withholding.
c.
If the Plan Administrator notifies you that the employee is subject to a waiting period that
expires more than 90 days from the date of its receipt of Part B of this Notice, or whose
duration is determined by a measure other than the passage of time (for example, the
completion of a certain number of hours worked), complete item 6 of the Employer Response to
notify the Issuing Agency of the enrollment timeframe and notify the Plan Administrator when
the employee is eligible to enroll in the plan and that this Notice requires the enrollment of the
child(ren) named in the Notice in the plan.
Page 4 of 5
DURATION OF WITHHOLDING
The child(ren) shall be treated as dependents under the terms of the plan. Coverage of a child as a dependent
will end when conditions for eligibility for coverage under terms of the plan no longer apply. However, the
continuation coverage provisions of ERISA may entitle the child to continuation coverage under the plan. The
employer must continue to withhold employee contributions and may not disenroll (or eliminate coverage for) the
child(ren) unless:
1.
The employer is provided satisfactory written evidence that:
a.
The court or administrative child support order referred to in this Notice is no longer in
effect; or
b.
The child(ren) is or will be enrolled in comparable coverage which will take effect no
later than the effective date of disenrollment from the plan; or
2.
The employer eliminates family health coverage for all of its employees.
POSSIBLE SANCTIONS
An employer may be subject to sanctions or penalties imposed under State law and/or ERISA for discharging an
employee from employment, refusing to employ, or taking disciplinary action against any employee because of
medical child support withholding, or for failing to withhold income, or transmit such withheld amounts to the
applicable plan(s) as the Notice directs. Sanctions or penalties may be imposed under State law against an
employer for failure to respond and/or for non-compliance with this Notice.
NOTICE OF TERMINATION OF EMPLOYMENT
In any case in which the above employee’s employment terminates, the employer must promptly notify the
Issuing Agency listed above of such termination. This requirement may be satisfied by sending to the Issuing
Agency a copy of Part A with response 4 checked or any notice the employer is required to provide under the
continuation coverage provisions of ERISA or the Health Insurance Portability and Accountability Act.
EMPLOYEE LIABILITY FOR CONTRIBUTION TO PLAN
The employee is liable for any employee contributions that are required under the plan(s) for enrollment of the
child(ren) and is subject to appropriate enforcement. The employee may contest the withholding under this
Notice based on a mistake of fact (such as the identity of the obligor). Should an employee contest the
withholding under this Notice, the employer must proceed to comply with the employer responsibilities in this
Notice until notified by the Issuing Agency to discontinue withholding. To contest the withholding under this
Notice, the employee should contact the Issuing Agency at the address and telephone number listed on the
Notice. With respect to plans subject to ERISA, it is the view of the Department of Labor that Federal Courts
have jurisdiction if the employee challenges a determination that the Notice constitutes a Qualified Medical Child
Support Order.
CONTACT FOR QUESTIONS
If you have any questions regarding this Notice, you may contact the Issuing Agency at the address and
telephone number listed on page 1 of this Notice.
Page 5 of 5
NATIONAL MEDICAL SUPPORT NOTICE
PART B
MEDICAL SUPPORT NOTICE TO PLAN ADMINISTRATOR
This Notice is issued under section 466(a)(19) of the Social Security Act, section 609(a)(5)(C) of the Employee Retirement
Income Security Act of 1974, and for State and local government and church plans, sections 401(e) and (f) of the Child Support
Performance and Incentive Act of 1998. Receipt of this Notice from the Issuing Agency constitutes receipt of a Medical Child
Support Order under applicable law. The rights of the parties and the duties of the plan administrator under this Notice are in
addition to the existing rights and duties established under such law. The information on the Custodial Parent and Child(ren)
contained on this page is confidential and should not be shared or disclosed with the Noncustodial Parent.
Issuing Agency: __________________________
Court or Administrative Authority: ___________________________
Issuing Agency Address: ___________________
Date of Support Order: _____________________
________________________________________
Support Order Number: ____________________
Date of Notice: _______________________
Case Number: ________________________
Telephone Number: ___________________
FAX Number: __________________
Employer Web Site:______________________
_____________________________________
RE: _______________________________________
Employer/Withholder’s Federal EIN Number
Employee’s Name (Last, First, MI)
_____________________________________
Employer/Withholder’s Name
_______________________________________
Employee’s Social Security Number
_____________________________________
Employer/Withholder’s Address
_______________________________________
Employee’s Address
_____________________________________
Custodial Parent’s Name (Last, First, MI)
_____________________________________
Custodial Parent’s Mailing Address
_______________________________________
Substituted Official/Agency Name and Address
(Required if Custodial Parent’s mailing address is left blank)
_____________________________________
Child(ren)’s Mailing Address (if Different from Custodial
Parent’s)
_____________________________________
_____________________________________
_____________________________________
Name(s), Mailing Address, and Telephone
Number of a Representative of the Child(ren)
Child(ren)’s Name(s)
__________________________
__________________________
__________________________
DOB
SSN
_______ ________
_______ ________
_______ ________
Child(ren)’s Name(s)
____________________________
____________________________
____________________________
DOB
SSN
_________ __________
_________ __________
_________ __________
The order requires the child(ren) to be enrolled in [] any health coverages available; or [] only
the following coverage(s): __medical; __dental; __vision; __prescription drug; __mental health;
__other (specify):______________________________
THE PAPERWORK REDUCTION ACT OF 1995 (P.L. 104-13) public reporting burden for this
collection of information is estimated to average 20 minutes per response, including the time
reviewing instructions, gathering and maintaining the data needed, and reviewing the collection
of information. An agency may not conduct or sponsor, and a person is not required to respond
to, a collection of information unless it displays a currently valid OMB control number.
OMB control number: 1210-0113 Expiration Date: 10/31/2012.
PLAN ADMINISTRATOR RESPONSE
(To be completed and returned to the Issuing Agency within 40 business days after the date of
the Notice, or sooner if reasonable)
Case #__________________ (to be completed by the issuing agency)
This Notice was received by the plan administrator on ________.
1. This Notice was determined to be a "qualified medical child support order," on _______.
Complete Response 2 or 3, and 4, if applicable.
2. The participant (employee) and alternate recipient(s) (child(ren)) are to be enrolled in the
following family coverage.
a. The child(ren) is/are currently enrolled in the plan as a dependent of the participant.
b. There is only one type of coverage provided under the plan. The child(ren) is/are
included as dependents of the participant under the plan.
c. The participant is enrolled in an option that is providing dependent coverage and the
child(ren) will be enrolled in the same option.
d. The participant is enrolled in an option that permits dependent coverage that has not
been elected; dependent coverage will be provided.
Coverage is effective as of __/__/____( includes waiting period of less than 90 days from date of
receipt of this Notice). The child(ren) has/have been enrolled in the following option (if plan is
insured, identify provider, policy and group numbers): _______________________. Any
necessary withholding should commence if the employer determines that it is permitted under
State and Federal withholding and/or prioritization limitations.
3. There is more than one option available under the plan and the participant is not enrolled. The
Issuing Agency must select from the available options. Each child is to be included as a
dependent under one of the available options that provide family coverage. If the Issuing
Agency does not reply within 20 business days of the date this Response is returned, the
child(ren), and the participant if necessary, will be enrolled in the plan’s default option, if any:
_______________________________________.
4. The participant is subject to a waiting period that expires __/__/____ (more than 90 days from
the date of receipt of this Notice), or has not completed a waiting period which is determined by
some measure other than the passage of time, such as the completion of a certain number of
hours worked (describe here: _________________________). At the completion of the waiting
period, the plan administrator will process the enrollment.
5. This Notice does not constitute a "qualified medical child support order" because:
The name of the child(ren) or participant is unavailable.
The mailing address of the child(ren) (or a substituted official) or participant is
unavailable.
The following child(ren) is/are at or above the age at which dependents are no longer
eligible for coverage under the plan _______________________________ (insert
name(s) of child(ren)).
Plan Administrator or Representative:
Name: ___________________________________ Telephone Number: _____________
Title:
___________________________________ Date: ________________
Address:___________________________________
INSTRUCTIONS TO PLAN ADMINISTRATOR
This Notice has been forwarded from the employer identified above to you as the plan
administrator of a group health plan maintained by the employer (or a group health plan to which
the employer contributes) and in which the noncustodial parent/participant identified above is
enrolled or is eligible for enrollment.
This Notice serves to inform you that the noncustodial parent/participant is obligated by an order
issued by the court or agency identified above to provide health care coverage for the child(ren)
under the group health plan(s) as described on Part B.
(A) If the participant and child(ren) and their mailing addresses (or that of a Substituted Official
or Agency) are identified above, and if coverage for the child(ren) is or will become available,
this Notice constitutes a “qualified medical child support order”(QMCSO) under ERISA or
CSPIA, as applicable. (If any mailing address is not present, but it is reasonably accessible, this
Notice will not fail to be a QMCSO on that basis.) You must, within 40 business days of the
date of this Notice, or sooner if reasonable:
(1) Complete Part B - Plan Administrator Response - and send it to the Issuing Agency:
(a) if you checked Response 2:
(i) notify the noncustodial parent/participant named above, each named child, and
the custodial parent that coverage of the child(ren) is or will become available
(notification of the custodial parent will be deemed notification of the child(ren) if they
reside at the same address);
(ii) furnish the custodial parent a description of the coverage available and the
effective date of the coverage, including, if not already provided, a summary plan
description and any forms, documents, or information necessary to effectuate such
coverage, as well as information necessary to submit claims for benefits;
(b) if you checked Response 3:
(i) if you have not already done so, provide to the Issuing Agency copies of
applicable summary plan descriptions or other documents that describe available
coverage including the additional participant contribution necessary to obtain coverage
for the child(ren) under each option and whether there is a limited service area for any
option;
(ii) if the plan has a default option, you are to enroll the child(ren) in the default
option if you have not received an election from the Issuing Agency within 20 business
days of the date you returned the Response. If the plan does not have a default option,
you are to enroll the child(ren) in the option selected by the Issuing Agency.
(c) if the participant is subject to a waiting period that expires more than 90 days from the
date of receipt of this Notice, or has not completed a waiting period whose duration is
determined by a measure other than the passage of time (for example, the completion of a
certain number of hours worked), complete Response 4 on the Plan Administrator
Response and return to the employer and the Issuing Agency, and notify the participant
and the custodial parent; and upon satisfaction of the period or requirement, complete
enrollment under Response 2 or 3, and
(d) upon completion of the enrollment, transfer the applicable information on Part B
Plan Administrator Response to the employer for a determination that the necessary
employee contributions are available. Inform the employer that the enrollment is
pursuant to a National Medical Support Notice.
(B) If within 40 business days of the date of this Notice, or sooner if reasonable, you determine
that this Notice does not constitute a QMCSO, you must complete Response 5 of Part B - Plan
Administrator Response and send it to the Issuing Agency, and inform the noncustodial
parent/participant, custodial parent, and child(ren) of the specific reasons for your determination.
(C) Any required notification of the custodial parent, child(ren) and/or participant may be
satisfied by sending the party a copy of the Plan Administrator Response, if appropriate. You
may choose to furnish these notifications electronically in accordance with the requirements of
the Department of Labor’s electronic disclosure regulation codified at 29 C.F.R. 2520.104b-1(c).
UNLAWFUL REFUSAL TO ENROLL
Enrollment of a child may not be denied on the ground that: (1) the child was born out of
wedlock; (2) the child is not claimed as a dependent on the participant's Federal income tax
return; (3) the child does not reside with the participant or in the plan's service area; or (4)
because the child is receiving benefits or is eligible to receive benefits under the State Medicaid
plan. If the plan requires that the participant be enrolled in order for the child(ren) to be enrolled,
and the participant is not currently enrolled, you must enroll both the participant and the
child(ren) regardless of whether the participant has applied for enrollment in the plan. All
enrollments are to be made without regard to open season restrictions.
PAYMENT OF CLAIMS
A child covered by a QMCSO, or the child’s custodial parent, legal guardian, or the provider of
services to the child, or a State agency to the extent assigned the child’s rights, may file claims
and the plan shall make payment for covered benefits or reimbursement directly to such party.
PERIOD OF COVERAGE
The alternate recipient(s) shall be treated as dependents under the terms of the plan. Coverage of
an alternate recipient as a dependent will end when similarly situated dependents are no longer
eligible for coverage under the terms of the plan. However, the continuation coverage provisions
of ERISA or other applicable law may entitle the alternate recipient to continue coverage under
the plan. Once a child is enrolled in the plan as directed above, the alternate recipient may not be
disenrolled unless:
(1) The plan administrator is provided satisfactory written evidence that either:
(a) the court or administrative child support order referred to above is no
longer in effect, or
(b) the alternate recipient is or will be enrolled in comparable coverage
which will take effect no later than the effective date of disenrollment from the
plan;
(2) The employer eliminates family health coverage for all of its employees; or
(3) Any available continuation coverage is not elected, or the period of such coverage
expires.
CONTACT FOR QUESTIONS
If you have any questions regarding this Notice, you may contact the Issuing Agency at the
address and telephone number listed above.
Paperwork Reduction Act Notice
The Issuing Agency asks for the information on this form to carry out the law as specified
in the Employee Retirement Income Security Act or the Child Support Performance and
Incentive Act, as applicable. You are required to give the Issuing Agency the
information. You are not required to respond to this collection of information unless it
displays a currently valid OMB control number. The Issuing Agency needs the
information to determine whether health care coverage is provided in accordance with the
underlying child support order. The average time needed to complete and file the form is
estimated below. These times will vary depending on the individual circumstances.
Learning about the law or the form
...........
Preparing the form
1 hr., 45 min.
First Notice
1 hr.
...........
Subsequent
Notices
-----
...........
20 min.